A Yellow Dot in
the bottom left
corner of the rear window of
your vehicle will alert all First Responders to the
vital medical information in your glove box. This
will help ensure that you receive the medical care you need during that
first ‘Golden Hour’ after a crash or other emergency.
You can be part
of the solution. Sign up for yourself and each member of
your family. Share the information with your friends and
neighbors, and all those who rely on you for
Sign up today and take advantage of this
to contact the Volunteer Center for details.
You can save the forms to your
personal computer so you can make changes as needed!
File for Life
This form contains all the information
needed by first responders to make sure
they have vital information about you
and your healthcare needs during that
critical first hour after an accident or
emergency. You may enter as much or as
little information as you want. It's
your form - your decision.
(Use this PDF file
if you cannot open
the Word file.)
Physicians Orders for Life Sustaining
Treatment Form (POLST)
This form complements an Advance
Directive and provides details regarding
your wishes regarding CPR, medical
interventions and other possible
treatments. Complete instructions and
important information is on the form.
You may also visit the POLST California
for additional information about
advanced care planning.
Save My Pets!
This form provides important information
about your pets and their particular
needs, including medications, allergies,
their veterinarian, and tips for you to
be sure they are cared for by making
emergency contact information available
to first responders.
Doctor Authorization Form
This document authorizes you doctor to
complete the File for Life and
Physicians Orders for Life Sustaining
Treatment (POLST) forms for your review
and subsequent approval and/or
Yellow Dot Brochure
This document contains information about
the Yellow Dot Program, including where
to sign up, partners, where to get files
and additional information.
Advanced Care Directive - HELP!
In order to ensure
that our wishes are carried out when we
cannot speak for ourselves, everyone
needs to have an Advance Care Directive.
The Advance Directive form available
below may be used to spell out in detail
all your instructions. If you're not
comfortable doing that yet, you might
consider something a little less
comprehensive. You can do this by
preparing a statement of your wishes,
sign and date it. Dr. John R. Dykers,
Jr., M.D. has shared his own end-of-life
plan as follows:
"if you can fix
me, please do. If you can't fix me,
please help me avoid pain, fear, lack of
air, hunger, nausea, thirst, loss of
dignity and prolonging the dying
process. I understand that it might take
a few days to figure out whether you can
fix me or not."
You can add your own words. This is a
good way to start and to facilitate the
Advanced Care Directive - FORM
You have the right to give instructions
about your own health care. You also
have the right to name someone else to
make health care decisions for you. The
Advanced Care Directive form lets you do
one or both of these things. It also
lets you write down your wishes about
donation of organs and the selection of
your primary physician. You may complete
or change any part of the form to meet
Calaveras Community Foundation
Mark Twain Hospital/Dignity Health
Robert and Barbara Jones
Calaveras Works & Human Services
Country Cliff’s Café
Calaveras Deputy Sheriff’s Association
Calaveras County Fire
Calaveras Senior Centers
The Volunteer Center
Calaveras Behavioral Health
Commission on Aging
Citizen Corps Council
American Legion Ambulance
Calaveras County Public Health
. . .
and Private Donations
Ways To Help -
you would like to volunteer or make a
financial contribution to ensure that this
resource is available to all our citizens,
please understand that no donation of time
or money is too small. . . it all adds up!
You can make a difference!
Calaveras Yellow Dot Program Committee
(209) 754-1699 EIN #45-4345879
196, San Andreas, CA 95249